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RESEA R C H Open Access
Harm reduction, methadone maintenance
treatment and the root causes of health and
social inequities: An intersectional lens in the
Canadian context
Victoria Smye
*
, Annette J Browne, Colleen Varcoe and Viviane Josewski
Abstract
Background: Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment
(MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT,
particularly how Harm Reductio n and MMT are experienced differently by people dependent on how they are
positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions
in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of
domination and oppression;
Methods: A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews
and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients
accessing mainstream mental health and addictions care and primary health care settings
and healthcare providers;
Results: All client-participants had profound histories of abuse and violence, most often connected to the legacy
of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism).
Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance
use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday
experiences both within and outside the system that further marginalize them. In this paper, we focus on three
intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing
enactment of peoples’ agency, and homelessness;
Conclusions: Harm reduction must move beyond a narrow concern with the harms directly related to drugs and
drug use practices to address the harms associated with the determinants of drug use and drug and health policy.
An interse ctional lens elucidates the need for harm reduction approaches that reflect an understanding of and
commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/
health, addictions, including harm reduction and methadone maintenance treatmen t.

There is considerable evidence that harm reduction
approaches are effective in reducing the harms associated
with drug use [1-3]. As Pauly notes, “harm reduction as a
philosophy shifts the moral context in health care away
from the primary goal o f fixing individuals towards one
of reducing harm“ (italics ours) (p.6) [4]. However,
although harm reduction opens opportunities for
promoting the health of people who often are stigmatized
through social r esponses to problematic substance use,
harm reduction interventions do not necessarily address
the root causes of substance use and attendant social
conditions that influence inequities in health and ac cess
to health care for this population - “inequities [that] are
exacerbated by lack of quality housing, poverty, une m-
ployment, lack of social support and education” (p.8) [4].
Harm reduction approaches that fail to address the
multiple intersections t hat influence peoples’ health and
* Correspondence:
University of British Columbia, School of Nursing. T201-2211 Wesbrook Mall,
Vancouver, B.C. V6T 2B5, Canada
Smye et al. Harm Reduction Journal 2011, 8:17
/>© 2011 Smye et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License ( which perm its unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
well-being and their experiences of and responses to
mental health and addictions care may also fail to
improve health in a meaningful way [5].
In keeping with the perspectives of Hankivsky, Cormier
and de Merich, we believe that peoples’ health and experi-
ences are shaped by a number of intersecting variables

associated with social identity, such as “race/ethnicity,
Indigeneity, gender, class, sexuality, geography, age, dis-
ability/ability, immigration status, religion etc. - variables
that also have been associated with oppression (e.g., racism
and classism) and consequent disadvantage (e.g., poverty
and homelessness)” (p.7-8) [6]. For example, in the study
in which this paper is grounded, the client participants
were Aboriginal, and ‘race’ was relevant to all experience -
the race-based privilege of oppression was present in t he
everyday reality of peoples’ lives, including the experiences
of accessing and delivering MMT. Yet ‘race’ could not be
neatly shifted apart from processes of racialization , issues
of gender, class relations, and other social relations that
structured peoples’ lives such as their education level,
employment status, health, and well-being. As Bannerji
notes, “[r]acism is after all a concrete social formation. It
cannot be independent of other social relations of power
and ruling which organize the society, such a s those of
gender and class ” (p.128) [7] - the relationship between
these variables is complex and interdependent [6,8-10],
occurring within and intersecting with societal contexts.
Anderson and Reimer Kirkham note that to understand
the meaning of health within a sociopolitical and cultural
context, there is a need for an elucidation of “the intersec-
tionality and simultaneity of race, gender, and class rela-
tions, the practice of racialization, the connectedness to
historical context, and how the curtailment of life oppor-
tunities created by structural inequities influences health”
(p.63) [11].
Intersectionality is increasingly being used in health

research as a lens for highlighting the inter-related and
co-constructed nature of social locations and experiences
[6,12,13], and for understanding differences in health
needs and outcomes in ment al health and addictions and
harm reduction [14]. As Weber and Parra-Medina note,
inequities are often obscured when models of practice
focus on individual bodies [and b ehaviour] rather than
taking into account “the social structural context as the
locus of a population’s health” (p.187) [12]. Grounded in
critical feminist theoretical perspectives, intersectional
analyses are useful in drawing attention to the dynamics
of the intersect ions between problematic substance use,
other aspects of social identity and different forms of
oppression associated with social and structural contexts
that can guide us in the pursuit of addressing the multi-
ple inequities and intersecting multiple stigmas asso-
ciated with drug use.
In this paper, we focus on harm reduction and metha-
done maintenance treatment (MMT) to illustrate how
social change can be promoted using an intersectional
lens to examine harm reduction and MMT and mental
health and addictions more broadly. We use findings
from a partnership-based research project conducted in
British Columbia, Canada, entitled, Aboriginal peoples’
experiences of mental health and addictions care: Toward
improved access, to elucidate how an intersectional lens
canprovideamorecomplexunderstandingofharm
reduction and MMT - how harm reduction and MMT
are experienced differently by people dependent on how
they are differently located (e.g., living in poverty and

homeless and/o r near homel ess) . Using the lens of inter-
sectionality, we refine the notion of harm reduction by
specifying the conditions in which both harm and benefit
arise and how experiences of harm are continuous with
wider experiences of domina tion and oppression. This
paper is not meant to be an indictment of harm reduc-
tion or MMT; rather, we use an intersectional lens to elu-
cidate the need for harm reduction approaches that
reflect an understanding of and commitment to addres-
sing the historical, socio-cultural and political forces that
shape responses to mental health and addictions and
harm reduction.
Background
The Complexity of Problematic Substance Use, Addiction
and Associated Stigmas
In this paper, our focus is on issues pertaining to proble-
matic substance. In particular, our research has focused
on people who identify as Aboriginal and who are most
impacted by the marginalizing conditions of persistent
social and structural inequities - poverty, homelessness,
unemployment and so on. From the outset, we want to be
clear that problematic substance use is not always asso-
ciated with mental illness, homelessness, Aboriginal iden-
tity etc., however, the issues discussed in this paper
represent insights provided by conducting research with
Aboriginal people whose lives have been most influenced
by these sociopolitical circumstances.
In keeping with the perspective of Reist, Marlatt, Gold-
ner, Parks and Fox, we understand the phrase ‘proble-
matic substance use’ to encompass the concepts of

potentially harmful substance use behavio urs or patter ns
(e.g., impaired driving or the use of substances during
pregnancy) that are not clinical disorders
and ‘ substance
use disorders’(i.e., clinical disorders defined by the DSM-
IV, including dependence or addiction) (p. 4) [15]- with a
spectr um of use from ‘beneficial’ to ‘no n-problematic’ to
‘problematic use’ (p. 8). From this perspective, substance
use is not problematic for everyone, and one substance
may present a problem for the individual where another
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 2 of 12
may not. In addition, substance use c an be stable at one
point in time and move gradually or rapidly to a different
point (p. 8) [15].
The associated harmful consequences of problematic
substance use may include physical illness, inclu ding
increased risk of infection (e.g., HIV, Hepatitis C and
other blood borne infections due to sharing drug para-
phernalia); family breakdown; economic issues; criminal
involvement; and a high risk of overdose leading to
death, and death by violence [16-19]. In addition, the
issue of stigma i s a highly pertinent concept inte rsecting
with [or contributing to] the harms associated with pro-
blematic substance use (p.5) [20,21].
In this paper we take up Goffman’ s (1963) notion of
stigma as an attribute associated with ‘difference’ that i s
deemed to be a less desirable difference by one person
(the stigmatizer) i n relation to another p erson (the st ig-
matized) - a difference, which at its extreme, might deem

the person as bad, dangerous or weak (stereotyping)
(p. 12) [22]. Further as Link and Phelan argue [23,24],
stigma is created through five interrelated and conver-
ging social processes, for example, in the case of drug
use: i) labeling of the person with problematic substance
use as different, e.g., the ‘drug addict’ or ‘junkie’; ii) nega-
tive stereotyping by linking ‘difference’ with un desi ra ble
characteristics and fears such as drug users as “ danger-
ous"; iii) ‘othering’ by creating “them” (the labeled
person) and “us” categories; iv) status loss, blame and dis-
crimination of the labeled person; and, v) creation of
power dynamics in which power is experienced by the
labeled person’s ability to access to key resources, such as
money and social networks/institutions [25,26]. Thus,
problematic substance use as a category of ‘difference’
often leads to stigmatization based on the beliefs that
underpin its perceived o rigins and an experience of and
the ability of the labeled person to resist stigma (or not)
dependent on their social location and perceived power.
Although public attitudes vary towards people with
problematic substance use and many people acknowledge
that people with drug use issues often come from difficult
circumstances, i.e., that there are social and structural
issues influencing use, there remains a strongly held vie w
that “drug addicts” are to blame for their drug use [27].
For example, Henderson et al. (2008) concluded that
while staff in their hospital study were committed to pro-
viding care to people with problematic substance use,
their training and experience led them to treat them dif-
ferently from other pati ents - particularly notable in the

area of pain management (as cited in Lloyd, (2010)) [27]
where physicians, as one example, are trained to the on
alert to “ drug seeking” behaviour in this population. As
Lloyd notes, in our society, the identity as “addict, tends
to take center stage to the obscuration of all other facets
of identity and personality ” (p.13)[27].
Additionally, individuals who are “addicted” or depen-
dent on substances often lead “chaotic and stressful”
lives and may have additional co-occurring and stigma-
tizing mental health and other health issues; these inter-
sect with social issues asso ciated with their substance
use that make diminishing or abstaining from su bstance
use extremely difficult (p.16) [17,21,26,28,29]. Chaos and
stress are most often related to intersecting factors, such
as poverty, unemployment, housing issues and stigma
and discrimination [17]. Lack of housing and/or mean-
ingful employment have also been shown to contribute
to substance use and addictions. In this paper, we use
an intersectional lens to s hift attention from the indivi-
dual to the social and structural inequities that may
influence substance use, and health and well-be ing for
those with problematic
substance use. For example, sub-
stance use needs to be understood as so metimes over-
lapping with violence and mental health issues, and
those problems need to be seen within the context of
social and structural determinants of health to ensure
the provision of integrated care [30,31].
Examining Harm Reduction and MMT through an
Intersectional Lens

Given the complexity of problematic substanc e and asso-
ciated stigma as presented above, the complexity of issues
that shape practices and policies related to MMT are best
understood under the pragmatic philosophy of harm
reduction (p.18) [17]; an approach that represents a con-
tinuum of services that embody a philosophical, prag-
matic and compassionate approach to providing care
while minimizing the negative harms associated with
substance use, understanding that not all people have the
same ability to change, the same level of drug use, or
even experience the same harms [5]. Two central under-
lying values of a pragmatic perspective to harm reduction
is i) that all life activities carry risk and ii)thatelimina-
tion of drug use is not necessarily attainable o r desirable
[4]. This approach t o harm reduction is goal-oriented,
humanistic [32] and in keeping with a cost benefit aware-
ness [5,33]. Humanistic values explicitly highlight the
values of respect, worth and dignity of all persons, there-
fore, there is a focus of “nonjudgmental acceptance of
persons [who use illicit drugs] as worthy of respect with-
out judgment of drug use” (p.6) [5]. The active participa-
tion of the client is acknowledged as important in harm
reduction programs [5,32].
Central to a harm reduction approach is “ a focus on
reducing the negative consequences of substance use for
individuals, communities and societies rather than
focusing on decreasing or eliminating substance use”
(p. 6) [5]. Harm reduction occurs gradually in a step-by-
step progression toward decreased levels of overall harm
[33]. In keeping with this perspective, harm reduction is

Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 3 of 12
one aspec t of a comprehensive approach to the harmful
consequences of drug use, recognizing that there are
many different strategies and programs of harm reduc-
tion that meet diverse clie nts’ needs. Health care profes-
sionals using a harm reduction approach meet clients
“wheretheyareat” in terms of their ability to change
(p.14) [33], and work collaboratively with clients to
establish goals and develop a client-centered plan of
care [17]. Lastly, a harm reduction approach is under-
pinned by a commitment to change policy and/or to be
integrated into existing health policies. Examples of spe-
cific harm reduction strategies include needle exchange
programs, safe injection sites, distribution of condoms
and dental dams (all products should be freely available
and offered without cost), bleach kit programs for clean-
ing syringes, distribution of clean crack kits, safer sex
education, safer drug use and education, outreach pro-
grams for high-risk populat ions, law-enforcement co-
operation, prescription of heroin and other drugs, and
methadone maintenance treatment, among others. How-
ever, most of these efforts deal directly with the harms
that emanate from individual drug using and sexual
practices, and deal less with the h arms associated with
the root causes of problematic substance use (violence,
poverty, racism, historical trauma and so on), and the
harms associat ed with drug po licy (such as criminaliza-
tion, incarceration, poverty). Although all important
strategies, the root causes of illicit drug use are not

addressed. MMT as a harm reduction strategy is an
exemplar of how an intersectional lens can elucidate the
multiple intersecting factors that shape experience.
As a substitution/maintenance therapy, MMT is consid-
ered the “gold standard” (p.6) [34]. “Systematic reviews
have identified MMT as the most effective form of treat-
ment for opioid dependence in terms of treatment reten-
tion and decreases in the use of illicit opioids” [[35-37] as
cited in 21]. Methadone is a long-acting synthetic opioid
that binds to the opioid receptors in the body. Being an
opioid agonist, it can significantly reduce the rates of with-
drawal and cravings associated with opioid dependence
[34]. Due to the fact that it is a long-acting drug, there is
no euphoric effect, a fact that contributes to lower rates of
relapse [16,17,34]. However, as Caplehorn et al. note, one
of the greatest benefits of MMT is its well documented
decrease in mortality for individuals in treatment as com-
pared to those who use opioids who are untreated [[38] as
cited in 21].
According to recent guidelines developed by the
RNA O, that are based on a systematic review of the lit-
erature, and according to Reist, MMT should ideally
encompass an interdiscipli nary effort with three compo-
nents: methadone prescribing, methadone dispensing
and a range of compr ehensive psych osocial services and
supports such as counseling services and supports
related to housing, employment, education, mental
health, or life skills and access t o other health services
such as perinatal care and health promotion activities
[17,21]- care that takes into consideration the biopsy-

chosocial context of the individual client.
Yet, MMT is often applied within biopsychosocial mod-
els in ways that encompass varied strategies but ignore the
intersecting social and structural issues that give rise to
opioid addiction, resulting in particularly serious conse-
quences for some groups of people - approaches that do
not focus on the social forces and contexts that shape peo-
ple’s health and lives, including “the situatedness of social
inequality in history and place, and its operation at the
macro social structural as well as micro individual level”
(p.187) [12]. MMT often involves regulating or managing
the social order and ‘ marginalized’ subjects, but fails to
deal with the root causes of injustice that give rise to drug
use. For example, harm reduction approaches, including
MMT, that do not reflect the simultaneous interactions
between substance use, gender, class, violence and trauma
as complex and interdependent, fail to address the unique
needs of women [30,31]. “Substance use and mental health
problems frequently co-occur among women who are sur-
vivors of violence, trauma, and abuse, of ten in complex,
indirect and mutually reinforcing ways ” (p.32) [31]. In
addition, HIV infection due to injection drug use is far
more prevalent in women, accounting for 19.2% of all
AIDS diagnoses in adult women compared to 3.9% in men
[39]. Harm reduction services need to attend to specific
needs of women and integ rate an intersectional analysis
into drug policy and harm reduction frameworks [30].
There is a need to apply what we know about differing
patterns, health impacts, pathways to p roblematic sub-
stance use and related experiences in the design of harm

reduction service provision and policy, including MMT.
An intersectional lens draws attention to how and why
MMT needs to reflect approaches that address the multi-
ple inequities, such as those associated w ith living with
mental health and addictions issues, a history of trauma
and violence, homelessness, and poverty - to name a few.
In addition to the above issues, the historical and struc-
tural inequities that have shaped the health and well-being
of Aboriginal people in Canada have resulted in greater
risks of experiencing violence, trauma [40-42] and sub-
stance use [43]. Yet l ittle is known about the experiences
of Aboriginal persons who access mental health and addic-
tions services (mainstream and Aboriginal). In 2006-2009,
we conducted a study in partnership with a team of Abori-
ginal and non-Aboriginal researchers, community agencies
and leaders in mental health and addictions and commu-
nity members to explore Aboriginal peoples’ experiences
of mental health and addictions care in an urban Canadian
context to inform the design of safe and effective [mental]
health and addiction services. In Canada, the term
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 4 of 12
‘Aboriginal’ is often used to refer to diverse groups of indi-
genous people who include First Nations, Métis, and Inuit
people.
Methods
Study Design and Data Collection
A qualitative design using ethnographic methods of in-
depth individual and focus group interviews and naturalis-
tic observation was used. Study participants were Aborigi-

nal clients from diverse Nations (as they described
themselves) including, Nisga’ a, Plains Cree, Cree,
Kwagiulth, Cowichan, Blackfoot, Métis, Gitxsan, Dené,
Saulteaux Cree, Ojibway, Sioux, Coast Salish, Haida,
Sto’lo, Sarcee and Six Nations (n = 39; individual in-depth
interviews (n = 18: 8 males, 10 females) and three focus
groups (n = 21: 11 males, 10 females) who accessed main-
stream and other mental health and addictions services
and health care providers, Aboriginal and non-Aboriginal
(n = 24; individual in-depth interviews) working within
those settings. Ethical approval was sought and obtained
by both the Behavioural Researc h Ethics Board of the
University (BREB #H06-80439) and the local ethics com-
mittee of the regional health authority. In addition, the
study was guided by ethical guidelines of the Royal Com-
mission on Aboriginal Peo ples (1993), and the principles
of Ownership, Control, Access, and Possession (OCAP)
for research with First Nations [44,45].
Purpo sive and theoretica l sampling was used to recruit
Aboriginal clients and health care professionals from men-
tal health and addictions settings. Because the purpose of
the study was to inform an understanding of how to
improve mainstream mental health and addictions services
sotheyaremoreresponsivetotheneedsofAboriginal
clients, the settings chosen were five community-based
mental health and primary health care agencies. Eligible
client participants were persons who had no cognitive
impairment and identified as 19 years or older, and Abori-
ginal persons acce ssing mental health and/or addiction s
services within these settings. Health professionals who

were interviewed were working within the research sites
and included the designations of mental health nurse
(RPNs, RNs, LPNs), community outreach worker, psychol-
ogist, psychiatrist, social worker and support worker.
Recruitment was facilitated through ‘liaison’ people on site
as well as through informational study pamphlets that
were approved by ethics and posted at the study-sites. The
qualitative interview/focus group guides for client partici-
pants prompted exploration in the following areas: the rea-
sons for seeking care in this particular setting; assumptions
and expectations about the care; experiences of seeking
car e; and, interest in Aboriginal tra ditional heal ing prac-
tices. The guide for health care providers prompted
exploration related to their experiences providing care to
Aboriginal clients and their understanding of why clients
seek care in their setting. Interviews occurred within the
mental health and/or addictions care setting or within an
informal setting and ranged between 30 and 60 minutes.
With permission, interviews and focus groups were audio-
taped and transcribed. An honorarium of $30 was pro-
vided as a way thanking participants for their time. All
participants were assured complete confidentiality and
provided written informed consent to the study.
Data Analysis
Using an interpretative thematic analysis, data was ana-
lyzed in a multi-step process using comparative coding
strategies [46,47]. Using NVivo, a computer software pro-
gram, transcripts were first coded in ‘chunks’ of data as a
means to organize and group the data. As new data con-
tinued to be gathered, whole interviews were read repeat-

edly to identify recurring, converging and contradictory
patterns of interaction, key concepts, preliminary themes,
illustrative examples and l inkages to theory [47]. In addi-
tion, coded transcripts were compared to identify simila-
rities and differences in the coding process. In this way,
initial coding strategies were rev ised and refined as part
of regular reflective discussions with the research team.
Finally, exemplars from coded categories and themes
were retrieved using NVivo a nd compared within and
across transcripts. At this point, interpretations were
reviewed using a sub-sample of participants to check
descriptive and interp retive validity. Resonating with par-
ticipan ts’ experiences of their complexity of life, the find-
ings of this study were discussed usi ng an intersectional
lens - as a set of complex inter relatio ns rather than a set
of discrete variables. For example, one of the core find-
ings which we discuss in this paper underscores the
importance of understanding how harm and benefit are
diff erentially experienced by clients of mental health and
addictions services dependent on their histories and
social location/position.
Results/Discussion
In this study, client participants presented with signi fi-
cant levels of co-occurring illnesses including schizoaffec-
tive disorder, moo d disorders, depression, anxiety,
suicidal ideation, alcohol and drug use, HIV, Hepatitis C
and PTSD associated with complex trauma. Several parti-
cipants were residential school survivors and most had
long histories of trauma, beginning in early childhood
and for many, continuing into the present. These factors

have been long understood to be associated with mental
health and addiction issues. For example, residential
schools which included industrial schools, boarding
schools, student residences, and hostels, loc ated through-
out Canada, the last of which closed in 1996, have been
the most often cited cause of the mental health concerns
of Aboriginal people in Canada. Although residential
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 5 of 12
schooling was not uniformly negative for all people,
5
its
overall impact has been devastating [48-53]. In response
to this understanding, in 2006, the federal government
announced the approval of the Indian Residential Schools
Settlement Agreement and the new Truth and Reconci-
liation Commission [54].
Many of the client participants in this study reported
being o n methadone, an aspect of the stu dy, we report
on in this paper. Further, all of the health care providers
worked with clients who had previously accessed MMT
or were attempting to access MMT. Using an intersec-
tional analysis, we use the findings of this study to
underscore the importance of understanding how harm
and benefit are differentia lly experienced by clients of
mental health and addictions services dependent on
their histories and social location/position.
The key findings were that a) stigma and discrimina-
tion intersected with other disadvantages to profoundly
shape people’s lives a nd their access to and experiences

with MMT, b) the policy context of MMT constrained
people’ s lives, with significant consequences and these
experiences and consequences varied with people’s social
locations, and c) in concert with poverty and other disad-
vantages, these constraints contributed to housing
instability and homelessness for many. Although harm
reduction is based on the values of non-judgment and
non-coercive approaches to service delivery [5] and there
are many positive ou tcomes associated with MMT, many
of the participants in this study experienced ‘harm’ asso-
ciated with “the intersectionality of disadvantages”
(p.763) [55].
Stigma and Discrimination
In keeping with the findings of several authors
[21,25,56], t he attitude of providers was cited as a bar-
rier to access to care in particular settings by several cli-
ent and health care professional participants. Our
findings provide a glimpse into how stigma and discri-
mination shape access to MMT. The following interview
exemplar illustrates the stigma experience of several cli-
ent participants (CP),
And its easy to kick a wounded dog, I mean, you
know, I mean that’s what happens down here, [ser-
vice providers] don’t mean to do it, they don’ tget
up in the morning with a plan to go ‘I’m going to go
kick ten junkies today,’ they don’tdoit,itsjustas
the day builds, as the day builds they just desensitize,
year after year they get desensitized to needs and
then they just start dealing with what the immediate
needs are.

For this participant, his identity as a “ junkie” int er-
sected with a perception of provider (physician)
desensitization and/or stigmatization of the “junkie” to
explain discriminatory treatment within the site where
he accesses methadone. Although this may not have
beenacaseofenactedstigma,i.e.,whereapersonis
actively discriminated against [22], this participant may
have perceived stigma [22,57] because of the negative
thoughts and feelings associated with an expectation of
stigma and discrimination e.g., through fear, shame
and guilt. It is not uncommon, for example, for clients
to experience “ MMT as punitive and shaming rather
than therapeutic even when the professional may be
trying to follow guidelines designed to protect the cli-
ent” (p. 15) [21]. Regardless of the dynamic or form of
stigma, stigmatization is a powerful force that often
interferes with access to MMT [21,27,56]. Indeed,
research ha s shown that ‘ drug user’ status can be a
barrier to accessing health care and can affect the
quality of care received [4,21,56,58,59]. A slightly dif-
ferent experience of discrimination is expressed by
another c lient in the following,
Within the system there is some prejudi ce people in
there and I try not to get too mad with them when I
findoutthatthey’ re prejudice, they don’ tlike
Natives and they don ’t like drug addicts.
For several participants in this study, in addition to
substance use as an axis of discrimination, stigma
(enacted or perceived) also was attached to an expecta-
tion of racia lization, a process that is neither neutral nor

without consequence. Given their multiple social loca-
tions, many people in this study expressed uncertainty
aboutwhytheyweretreatedpoorlybysomeproviders.
For example, living as an A boriginal person in Canada
carries with it the “burden of history” [60 ], and prejudice
and racism continue to manifest as new forms of colonial
processes and practices erupt; however, persons living
with mental illness and/or substance use issues and/or
HIV/AIDS and/or Hepatitis C also live with stigma and
prejudice associated with those diagnoses [26,61 -63] and
consequent life circumstances, such as poverty and incar-
ceration. Sadly, the social construction of identity/identi-
ties (including disease o r illness associated and group
identity (p. 3) [26]) interferes with both the ability of peo-
ple to acce ss and remain in MMT. In keeping with the
perspective of Stuber, Meyer, & Link [64], in our
research, we h ave found that analysis of the issues using
a singular focus on racism or classism or problematic
drug use (as examples of oppression), misses how the
meaning and experiences of stigma and prejudice inter-
sect with other important variables to create new forms
of discrimination. The stigma associated with drug use is
usually only one aspect of an intersecting set of stigmas
(p. 47) [27].
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 6 of 12
Applying an intersectional approach to analyses of
experiences of stigma and discrimination has numerous
advantages. It acknowledges the complexity of how peo-
ple experience stigma and discrimination and recognizes

that the experience of discrimination may be unique. It
also takes into a ccount the social context of the group.
It places the focus on society’ sresponsetotheindivi-
dual as a result of t he confluence of various factors and
does not require the person to slot themselves into rigid
compartments or categories, i.e., it captures more fully
the r eality of stigma and discrimination as it is experi-
enced by individuals. This approach allows the particu-
lar experience of stigma and discrimination, based on
the intersection of factors involved, to be acknowledged
and remedied. Attention to multiple disadvantaged
social statuses is important to identifying the root causes
of health disparities [65] and to designing effective inter-
ventions [64].
In the following interview example, a provider (P)
working in a harm reduction setting discusses metha-
done maintenance treatment,
Those on the methadone program their ultimate
objective is to get on methadone and stay on metha-
done and stay off heroine and then they can use
other drugs and there’s no consequence to that, other
than its affecting their health and it affects the, you
know, the methadone and so on and because I’m
an addictions counselor I have a hundred and twenty
patients on the methadone maintenance program .So
those pati ents are referred to a counselor for support
and for counseling and also to deal with any other
substance abuse that they may be experiencing. In
about eighty-five percent of the cases those on the
methadone program have a dependency on crack,

cocaineorsomeotherdrugsomyroleistodoan
assessment and refer them to day programs or treat-
ment centers or to out patient counseling to help
them more in a harm reduction philosophy My pre-
ference is abstinence, abstinence because of the
health, you know, it promotes health
This excerpt reflects the policy context in which MMT
is situated, i) a shoestring approach is supported (120 cli-
ents), ii) there is an absence of attention to the social
determinants of health, and iii) policies are constrained
by the criminalization of drug use. It obviously also
reflects the attendant discourses taken up by some health
care professionals working in the field. Although our
observations of the care provided in this setting suggest
that the community of professionals within the organiza-
tion, including this individual, generally were committed
to the provision of compassionate non-judgmental care
within a harm reduction framework, the ideology
projected by this provider belies a frustration with MMT
and drug use more broadly - a reflection of the perspec-
tives of many people in broader society.
Today, many people believe that MMT perpetuates
drug use because of the misconception that it merely
replaces one addictive opioid wit h another rather than
seeing it as a treatment for opioid use [32]. As Cheung
observes, this school of thought often is associated with
the idea that abstinence-oriented treatment is the only
way to achieve a “ drug-free ” state in society [32]. This
ideology is also perpetuated in treatment programs that
do not accept cli ents on methadone. As one client par ti-

cipant noted, “Yeah, I think that they should put more
treatment centers out there that are accessible to metha-
done [patients] because a lot of them don ’t accept
methadone [patients].” Societal and institutional stigma,
reflected in the political commitment and resources
available to harm reduction programs, client positioning
within the health care system and attitudes of health care
professionals can pose significant barriers to the accessi-
bility of MMT and other harm reduction programs for
opioid dependent individuals [4,66]. As Keane notes:
Prohibitionist policies threaten the freedom of users,
damage their health and constitute them as marginal
and stigmatized subjects excluded from normative
categories of citizenship such as ‘the general public’
(p.229) [67]
Participant experiences of health care in this study were
not influenced by one dimension of inequity, rather they
were influenced by differe ntial access to the social deter-
minants of health and related multiple intersecting
dimensions such as racism, classism, abilism and so on -
dimensions that intersect with dominant ideologies
regarding drug use and attendant assumptions, stereo-
types a nd values. As Benoit notes, “[t]hose who face ser-
ious health concerns and at the same time are subject to
multiple stigmas by virtue of their age, sex, gender, sexual
orientation, race, ethnicity, socioeconomic or other social
determinants, are less likely to access key resources and
therefore differentially positioned to buffer themselves
against the damaging impact of intersecting stigmas”
(p. 5)[26].

Constrained Lives: Harm Reduction, MMT and Individual
Agency
Although MMT supports access to other interventions
(e.g., anti-retroviral therapies) and there can be numerous
positive outcomes, some participants found MMT highly
restrictive; individual choice and freedom were limited by
the policies and pr actices attached to MMT. A s Young
notes in her examination of the notion of ‘inequality,’ insti-
tutional structures and processes (including institutional
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 7 of 12
rules and policies) “can inhibit the capacities of some peo-
ple” at the same time as they expand the options of others
(p.10) [68]. Many of the pa rticipants in our s tudy
described the ways in which their lives have been con-
strained by MMT. Individual agency was affected in sev-
eral ways. Limits were placed on the freedom of some
people to move from one area to another and choices
were limited by power inequiti es. For example, several of
the women in the study had children, who had been
apprehended by the state a s a consequence of the complex
intersections of poverty, gender and problematic drug use
and attendant social circumstances such as difficulties
accessing safe housing; they described difficulty visiting
their children because they could not access enough
methadone (carries) to make the trip i.e., t hey were on
daily doses of methadone and/or they could not access a
pharmacy that dispensed methadone where their children
were living, and/or they could not afford reliable transpor-
tation (sometimes needing to hitchhike) to see their

children.
Although many people (Aboriginal and non-Aborigi-
nal) experience the effects of the limits placed on agency
through restrictive guidelines regarding MMT, Aborigi-
nal experiences of MMT are impacted by sociopolitical
factors that are unique to their experience. For example,
Aboriginal children represent approximately 40% of the
76,000 children and youth placed in care in Canada [69]
- a fact associated with poverty, problem substance use
and inadequate housing [70](notably Aboriginal people
only comprise 4-5% of the overall Canadian population).
These conditions mediate the extent to which women
report substance use patterns and access MMT and
other harm reduction services. To provide effective and
safe harm reduction, including MMT and other services,
it is necessary to understand the social context(s) in
which these experiences emerge [71,72].
In a similar but s lightly d ifferent vein, several partici-
pants experienced MMT as being incompatible with a
“normal” li fe and improved quality of life. In the follow-
ing example, a client participant discusses such limita-
tions,
I’ m going to be up there this summer or next
summer [to see my relatives], but I’m on methadone
right now so I have to get off the methadone, I’m
only on twenty-two mls (millilit ers) but by June I
should be off.
A health care professional also discusses this issue in
the following,
How can you travel with a drug habit? A raging drug

habit try and get that [methadone], it would be a
nightmare to try and get that , so me doctor in
another province or something or other comm unity
to prescribe it, good luck try and navigate that
whole thing on your own
For the client participant above and as the health pro-
fessional notes, MMT can be highly constraining, includ-
ing the lack of freedom to travel because of the inability
of many to access methadone in other locales. However,
what was also problematic in this case, as noted in a later
discussion with this participant, was that MMT was not
experienced as an informed choice. He believed he had
been coe rced by his doctor inappropriately; he perceived
that he had used heroin minimally and now, six years
later, he experi enced MMT as seriously constraining - an
experience shared by several other participants.
In keeping with the perspective of this client, a health
care professional critiques the issue of “recruitment” to
MMT as problematic in the following interview example,
“I mean look at the methadone scene, I mean these drug s
started to pop up all over not because they care for the
people, [but because] there is money!” In our study, there
was a general cynicism expressed regarding how MMT is
being offered by some providers. Although most partici-
pants (clients and health care professionals) accepted
MMT as a harm reduction approach, several believed
that it was being used by some in power, such as a few
“doctors and pharmacists”, as a means to make money
“offofthebacksofaddicts.” In our study, these views
were fueled by a Canadian Broadcasting Corporation

(CBC) news headline on September 11, 2008 that read,
“Methadone kickbacks could lead to criminal investiga-
tion"; allegedly, several local pharmacies were reported to
be paying “ drug addicts” a fee each time they were dis-
pensed methadone - money that was reportedly being
used by some to buy illicit drugs [73]. In addition, the
practice of charging daily dispensing fees rather than
weekly dispensing fees ($15/day) was alleged to be the
practice in some pharmacies, even though “weekly dis-
pensing” was written on the prescription. The experience
of ‘being taken advantage of’ because of being an “
addict”
in addition to the rules and regulations associated with
MMT engendered a sense of vulnerability, and, to a belief
by some participants, that they were being punished for
their drug use. Although people with problematic sub-
stance use are not inherently vulnerable to stigma, they
do face disadvantages relative to their ability to access
resources and enact agency, i.e., enact control over their
bodies and lives.
The “regime of control” has been reported elsewhere in
the methadone literature in relation to random drug tests
and urine screens that are used to ensure people using
methadone are not “topping up” with illicit heroin or
other drugs [74] as well as methadone consumption [25];
according to Vigilant, there is a ‘felt’ or ‘perceived’ stigma
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 8 of 12
associated with these sorts of institutional regulations
[74,27]- a perception that is created by policies that rein-

force societal biases, e.g., those biases based in a moral
stance against drug use, rather than those that focus on
the sociopolitical and cultural context in which drug use
occurs. For people most marginalized by social and struc-
tural inequity such as Aboriginal people, ‘constrained
lives’ may make them the target of profound stigmatiza-
tion that may appear as insurmountable because of other
intersecting issues, poverty, homelessness and so on. In
addition to the constraints posed by treatment itself,
many of the participants in this study (79%) were also
constrained by unstable housing a nd limited options
related to same.
Harm Reduction, MMT and Homelessness
Women and men whose poverty leads them to live in
unsafe housing units in sections of the city where pro-
blematic drug use surrounds them, whose need for
access to MMT and antiretroviral treatment leads to
confinement to particular urban settings, and whose
Aboriginality may further limit their housing choices
within particular areas, exemplify the need to examine
harm reduction and MMT using an intersectional analy-
sis. An Aboriginal participant who was accessing MMT
in our study describes his living arrangements in the fol-
lowing, “ Native hou sing, you know what, it’sareal
crack house right? I wish I worked there, yo u know, at
nights, I wish they hired me at nights not to let people
in, I wouldn’ t.” For this participant and many others,
housing conditions acted as a barrier to positive out-
comes. Here, an intersectional lens draws attention to
the disturbing ways that homele ssness, poverty, sub-

stance use and racialization intersect to e xacerbate peo-
ples’ experiences of social suffe ring, i.e., to those human
conditio ns with roots and consequences associated with
social, economic and political power - suffering that is
both created by the way power is inflicted on human
experience and how this power shapes the response to
it. As noted by Kleinman et al., “the trauma, pain and
disorders to which atrocity gives rise [ongoing colonial
processes a nd practices] are health conditions; yet they
are also political and cultural matters” (p.ix) [63].
Another participant, an Aboriginal woman who lives
with HIV illness, Hepatitis C and mental illness,
describes her experience in the following,
There must be something wrong with me, I won’tgo
shower, I take sponge baths in my room the hotel
is so skungy we share a bathroom like if its
catchable
For this woman, the hotel she was liv ing in generated
tremendous fear of further health compromise. The
vermin and filth of the hotels where many of the partici-
pants in this study reside is well docum ented in other
places [75]. Although the lives of t he Aboriginal men
and women with mental health illness on MMT who
are living in poverty resemble those of other impover-
ished people, the intersection of poverty, mental illness,
HIV/AIDS, Hepatitis C, and gender (as examples) brings
with it a special set of c ircumstances and challenges to
successful harm reduction. We argue that intersections
across these multiple axes of differentiation do not have
additive effects; rather the findings of our study suggest

that peoples’ experiences, although similar across some
dimensions, are differentiated by the disadvantages (and
advantages) posed by their location across these axes.
Conclusions
Harm reduction, including MMT, “driven solely by redu-
cingtheharmofdruguseisnotsufficienttoaddress
inequities in health and access to health care for those
who are street involved” (p.8) [4]. As Pauly notes, the
root causes of problematic substance use must be
addr essed in conjunction with t he social determinants of
health [4], determinants such as stigma. The harms that
emanate from drug policy and health policy must also be
considered.
Regardless of the intent of health care providers, stigma
and discrimination were experienced by the participants
in our study in everyday attempts to access mental health
and addictions services, including harm reduction ser-
vices. In keeping with the perspective posed by Stuber et
al. [64], our research points to the need for more work to
be done to fully understand the often unintentional
impact of stigma and discrimination as social processes
linked to the reproduction of inequality and e xclusion,
and the many ways in which stigma and discrimination
affect persons marginalized by social and structural
inequity, including the possible negative consequences
related to health and well-being. As Rossiter and Morrow
argue, “the adoption of an intersectional perspective and
anti-oppression framework in anti-stigma and discrimi-
nation work will both allow for greater understanding
and awareness of intersecting social identities and the

layering of stigma and discrimination, and promise better
outcomes for the reduc tion of stigma and discrimination
at both social and structural levels” [14]. In addition, as
Lloyd notes, the entrenched and widely held view that
persons who use drugs are solely culpable for their condi-
tion needs to be addressed [27]; people, including health
professionals and the media regarding the causes and
nature of addiction.
People’s lives were also constrained by the way in which
services were offered. Employment opportunities, access
to children, attachments to family and community in
other geographic locations and so on, were constrained by
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 9 of 12
treatment. In our research, we have found that some
women’s capacity to parent is limited by MMT policies
regarding carries and social housing policies related to
children. To determine the constellation of risks for a
woman in the context of being, as one example, a single
mother in MMT, Aboriginal, unemployed and homeless
or near homeless, we need to explore how and where
these identities intersect to shape this woman’s personal
experience. As Collins et al. discuss, in the context of
research examining the constellation of intersecting risks
for inner city women with severe mental illness [8], we
must understand the multiple systems of power at work in
women’slives.
Lastly, in this study, most of the participants were liv-
ing in unstable housing or were homeless. We define
homelessness in much the same way as Patterson et al.

[76] to include both the absolutely (“street”) homeless as
well as those at imminent risk of homelessness. The
paths i n and out of homelessness usually involve some
form of inadequate housing. In a ddition, “ while the
most visible homeless individuals are those living on the
streets, many more individuals are precariously housed
in rooming houses, transiti onal housing, substandard
rental suites, shacks and c abins without runn ing water,
and other forms of substandard or unaffordable hous-
ing” - those individuals who are bot h inadequately
housed and inadequately supported are particularly
at-risk for homelessness (p. 17) [76]. Absolute homeless-
ness refers to those without any physical shelter. Hous-
ing is considered an important social determinant of
health and housing for Aboriginal peoples is notably lag-
ging in comparison to non-Aboriginal people in both
urban and rural settings. For example, it is estimated
that 41% of all Aboriginal peoples in British Columb ia
(BC), Canada are at-risk of homelessness and 23% are
absolutely homeless [76,77]. People with severe addic-
tions and/or mental illness also can be found in this
group - they make up anywhere from 33% to over 60%
of the overall homeless population [76].
Although harm reduction is not a panacea and it is
not feasible to believe that i t will address all social
oppressions, as Boyd notes, “harm reduction initiatives
can provide a shift in policy and practice that bring
social factors to the foreground. It can also pave the
way for compassionate health and human-rights m odels
of care, and the rejection of drug policy based on puni-

tive ideology” (p.5) [ 78]. However, harm reduction must
move beyond a narrow concern with the harms directly
related to drugs and drug use practices to address the
harms associated with the determinants of drug use,
such as homelessness, and the harms of drug and health
policy.
To consider long-term structural change in broad
social systems is a daunting task, b ut operating from a
social j ustice framework, it is one that we see as essen-
tial to making any substantial headway to address health
disparities. Concerted political action as well as the
forging of alliances across the domain s of many groups
- policy makers; researchers w orking from multiple
paradigms which include participatory and c ommunity-
based approaches; the media; grassroots activists; profes-
sional organizations; and most importantly, community
groups, are needed to bring about the kinds of change
necessary to reduce health disparities [6,12].
Pauly argues for harm r educt ion approaches/interven-
tions that integrate more fully with “primary health care
and the social determinants of health within a social jus-
tice framework” (p.8) [4]. In addition, we argue for rela-
tional practices that mitigate the effects of social
inequity and address mental health and addictions ser-
vices, including harm reduction - p ractices that reflect
an understanding of the ways in which health and well-
being (and health care) are shaped by the contextual
features of peoples’ lives [79]. Harm reduction tools,
including MMT, need to refle ct an understanding that
systems of power/oppression that operate across the

axes of race, class, gender, ability and so on, are inter-
locking; to focus on drug use to the exclusion of other
factors is problematic.
List of Abbreviations
MMT: Methadone Maintenance Treatment; PTSD: Post Traumatic Stress
Disorder; RNAO: Registered Nurses Association of Ontario.
Acknowledgements
This research was funded by the Canadian Institutes of Health Research
(CIHR). We also gratefully acknowledge: Dr. Evan Adams, Dr. Betty Calam, Ms.
Nadine Caplette, Dr. Elliot Goldner, Ms. Tonya Gomes, Dr. Peter Granger, Ms.
Barbara Keith, Mr. William Mussell, Mr. Perry Omeasoo, Dr. Paddy Rodney, Dr.
Colin van Uchelen, co-investigators; Ms. Lorna Howes, Mr. Sri Pendakur, Mr.
Ron Peters, Ms. Deborah Senger, Ms Leah Walker, collaborators; Ms. Tanu
Gamble, Social Science Researcher; Ms. Viviane Josewski, Research Manager;
Ms. Nancy Clark, Research Assistant, Ms. Tej Sandhu, Student. In addition, we
are grateful to our Community Aboriginal Advisory Team for their time and
support to this research and in particular to Ms. Roberta Price and Ms.
Doreen Littlejohn (also a collaborator). For the duration of this study, Dr.
Victoria Smye was supported by a CIHR New Investigator Award (2006-2009).
Dr. Annette J Browne is supported by a CIHR New Investigator Award and a
Scholar Award from the Michael Smith Foundation of Health Research.
Authors’ contributions
VS was the principle investigator on the study, designed and participated in
all aspects of the study, including the data analysis and interpretation of the
data and drafted the manuscript. AJB was a co-investigator, assisted in the
design and in all aspects of the study, including the data analysis and
interpretation of the data and assisted with the drafting of the manuscript.
CV assisted in the interpretation of the data and the drafting of the
manuscript. VJ participated in data analysis and interpretation of the data
and assisted with the final draft of the manuscript. All authors read and

approved the final manuscript.
Conflicts of interests
The authors declare that they have no competing interests.
Received: 13 February 2011 Accepted: 30 June 2011
Published: 30 June 2011
Smye et al. Harm Reduction Journal 2011, 8:17
/>Page 10 of 12
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doi:10.1186/1477-7517-8-17
Cite this article as: Smye et al.: Harm reduction, methadone
maintenance treatment and the root causes of health and social
inequities: An intersectional lens in the Canadian context. Harm
Reduction Journal 2011 8:17.
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